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Applications Will Be Processed When Submitted Properly Completed:Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> add ► I�r� (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATERQUALITY r 6S$'-- 2-30-- <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permit toconstruct and/or install the work herein described.This application is <br /> made in compliance with Sap Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address vjesl k a- UtieS i ity/Town <br /> Owner's Name �h / Phone y <br /> Address Q 0 a . City ,r <br /> Contractor's Name iWa4 License# lik W3t7l3usiness Phone <br /> Contractor's Address Emergency Phone ' o�� <br /> Is Certificate of Workman's Compensation Insurance on File With LHD? Yes •� _ {t No P" <br /> TYPE OF WORK (CHECK): NEW WELL:[] 'DEEPEN ❑` `'/RECONDITION❑ "-_�"'DESTRUCTION❑ r l <br /> WELL CHLORINATION ❑ WELL.ABANDONMENT ❑ OTHER © PUMP,INSTALLATION ❑ PUMP REPAIR IN � r <br /> REPLACEMENT❑ ; N <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines ` w Pit Privy <br /> Sewage Disposal Field _F Cesspool/Seepage Pit Other y. <br /> Property Line Private Domestic Well Public Domestic WeII <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well'Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED r Dia. of Well'Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing " <br /> IRRIGATION _ 11 GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODiC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL • ❑ OTHER T Other'Inforrhation <br /> L w <br /> ❑ GEOPHYSICAL ' _ Surface Seal installed By: <br /> PUMP INSTALLATION: Contractor ot.1all I #. G <br /> Type of Pump H.P. $ <br /> PUMP REPLACEMENT: ❑ State Work Done ` <br /> PUMP REPAIR: State Work Done <br /> .� A <br /> DESTRUCTION OF WELL: _ : Well Diameter '- Approximate Depth <br /> 1 <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in'accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit rC <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." ` <br /> I ill call for a Grout i Sp Eion riafir to gr. uting end final inspection. <br /> Signed Title: Date: �, <br /> (Draw Plo Ian on Reverse Side) <br /> 001 (7 <br /> • <� FOR DEPARTMENT USE ONLY <br /> PHASE I '"' —�s .. p <br /> Application Accepted By _ pate V <br /> Additional Comments: <br /> Phase II Grout Inspection -1 se Ill Final Insp�e tion Cy ' <br /> Inspection By Date r Inspection By. C�-A.te _z T, <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 6 Received By July.31 <br /> REMIT <br /> BILLING' REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE f <br /> i <br /> LESS I <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> a <br /> OTHER <br /> it <br /> OTHER <br /> 'i <br /> ii <br /> I. <br /> Received by t Date Receipt No. _ Permit No. Issua a pate Mailed Delivered <br /> n <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,iaox 2009 STOCKTON,CA 95201 <br />